2010_0209Feb 15 2010 2:16PM FIRE POWER SYSTEMS
CHECK ONE:
(972)641 -5480 p.4
IRRIGATION DOMESTIC %t FIRELINB
BACIG' WW PREVENTION ASSEMMLY TEST AND MAINTENANCE REPORT
NAME OF PWS: (�+' + o� Goe Pe 1 i
PWS LD. #
LOCATION OF SERVICE: SOO Fri par+ P4r kw&4
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Press= Principle 0 Pressure Vac = Breaker
X Double Check Valve O Annosphere Vacuum Breaker
Manufacuzrer WA4S Size Z %`
Model Number 007 M 141: Located At APA 04- F,
Serial N=ber 121003 �! ► N e{ r +s 3 +u e.�r v.t l f
The above is certified to be true.
Firm Name `;rs. P.W« 5 lPL-
FiMAdd=s 1111 i2v3ilci 6e;oj
C2/A...jj 0,-Ai`rl4L- I TX 7r6rd
Gauge # 3 7 2 7 7
Date last accuracy tested / -2,� /0
Cectirw Tester t� �,� �v Swr • srM, ,
Cert Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VAC LTM BREAKER
Doable Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ](
RP' l_ 4 ps:d
L=L-ed ❑
Cloud Tight
Leaked ❑
! . 4
Opened at
id
Opened at
Did not Open ❑
id,
Leaked O
R.apairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
_P sid
sid
R.P sid
The above is certified to be true.
Firm Name `;rs. P.W« 5 lPL-
FiMAdd=s 1111 i2v3ilci 6e;oj
C2/A...jj 0,-Ai`rl4L- I TX 7r6rd
Gauge # 3 7 2 7 7
Date last accuracy tested / -2,� /0
Cectirw Tester t� �,� �v Swr • srM, ,
Cert Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy